Chapter 6: Heart Disease

INTRODUCTION

Cardiovascular disease (CVD) is the leading cause of death among women worldwide, causing 1 in every 4 female deaths.¹ Although 1 of 4 women in the United States has some form of CVD, only 54% of women recognize that heart disease is their number 1 killer.² Multiple studies have noted that women tend to have a higher mortality and morbidity from cardiovascular events compared to men. Women are less likely than men to receive aggressive or invasive treatment for heart disease compared to men.³ There is also often a failure for both health care providers and women themselves to recognize either the underlying risks or the associated symptoms of CVD.⁴ It is therefore imperative for health care providers to understand its risk factors and recommendations regarding the management of this disease.

RISK CALCULATORS

Calculation of a woman’s 10-year risk of cardiovascular events is an important step in assisting women to know which modifiable risk factors could influence the risk of future disease. A 10-year risk score of CVD has become standard as an assessment tool for risk stratification. A 10-year risk of coronary heart disease (CHD) can be determined based on age, gender, and conventional risk factors, including high blood pressure (BP), dyslipidemia, glucose intolerance, and smoking.⁵

The first major model was the Framingham risk calculator. The original Framingham risk prediction algorithm to predict CHD (known as FRS-CHD) incorporated age; sex; diabetes; systolic and diastolic BPs; levels of total, low-density lipoprotein, and high-density lipoprotein cholesterol; and smoking to estimate a 10-year risk for angina, myocardial infarction (MI), or death due to CHD.⁶

Despite their prominent use, the applicability of Framingham-based algorithms to modern populations has been questioned.^7,8,9 Framingham-based scores are based on a homogeneous, geographically limited, Caucasian, male-dominated cohort from a prior generation when cardiovascular risk profiles and preventive pharmacotherapy were both less well developed and less used than in modern cohorts. Multiple studies in diverse populations suggest that Framingham-based risk-scoring systems may misclassify risk, particularly in women, and overestimate CHD risk.⁹ In response, the Reynolds Risk Score (RRS) was developed in 2007 and included parental history of premature CHD and measurement of high-sensitivity C-reactive protein.⁸ Most recently, the American Heart Association (AHA) and the American College of Cardiology (ACC) developed a new atherosclerosis cardiovascular disease (ASCVD) risk score to guide ASCVD risk-reducing therapy.¹⁰ This new risk score uses the same traditional risk factors as the original FRSs and offers separate equations for white and African American men and women. As noted, each risk model has its limitations and therefore should be used with caution. In women, using the Reynolds score as adjunct to other risk scores may yield value for reclassification, especially for those patients who fall into the intermediate-risk category.¹¹

Taking into account the tools and current ...